Portugal. From SACiUCI to InfAUCI. Sepsis epidemiology: an update. You re only given a little spark of madness. You mustn t lose it.

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1 Sepsis epidemiology: an update Portugal João Gonçalves Pereira ICU director Vila Franca Xira Hospital From SACiUCI to InfAUCI You re only given a little spark of madness. You mustn t lose it. Robin Williams

2 Cardoso, Crit Care, 2010, 14: R ICUs Identification of 897 (22%) patients with community-acquired sepsis ICUs Gonçalves-Pereira, Clin Microbiol Infect 2014, 12: 1308 Identification of 1556 (44%) patients with sepsis on ICU admission

3 Community acquired sepsis admitted to the ICU N Age (years) 60 (±18) 61 (±17) Infection on admission to the ICU SAPS II 44 (±18) 45 (±18) SOFA 7.4 (±3) 7 [1-15] Charlson Score Lenght of stay (ICU) 5 [0-15] 6 [2-21] 6 [2-34] Lenght of stay (H) 19 [3-86] 19 [3-86] Year

4 Infection Incidence Infection Infection 22% Community 30% 56% N= % Hospital 14% Cardoso, Crit Care, 2010, 14: R83 N=3572 Gonçalves-Pereira, Clin Microbiol Infect 2014, 12: 1308

5 Infection Incidence Infection Infection 14% 78% 22% 17% 5% 56% 30% 24% 6% Community Community N=4142 Health Care associated N=3572 Health Care associated Gonçalves-Pereira, Clin Microbiol Infect 2014, 12: 1308 HCA/CAI 23% (), 20% ()

6 Infection Source Roughly 60% of infections were from the pulmonary tract (either pneumonia or tracheobronchitis)

7 data Gonçalves-Pereira, Clin Microbiol Infect 2014, 12: 1308

8 data Positive microbiology 40.5% Appropriate antibiotic 81.6% Gonçalves-Pereira, Clin Microbiol Infect 2014, 12: 1308

9 Isolated Microrganisms Gram + Gram - Fungi Virus Others

10 Isolated Resistant Microrganisms Acinectobacter spp Pseudomonas spp Klebsiella spp 38 Staphylococcus aureus MR 16 (20%) CAI HCA Hospital Oxacillin resistance CAI 31.9% HCA 60.7% H 67.9%

11 Sepsis Stratification on ICU admission Sepsis Sepsis Stratification Severe sepsis Septic Shock Length of Stay ICU 9 (10) vs 8 (36) Hospital 19 (9) vs 22 (86)

12 Impact of Infection on mortality No infection Infection ICU mortality 23% 30% <0.001 Hospital mortality 32% 38% No infection Infection ICU mortality 19% 27% <0.001 Hospital mortality 26% 38% <0.001 Gonçalves-Pereira, Clin Microbiol Infect 2014, 12: 1308

13 Impact of Infection on mortality No infection Infection ICU mortality 23% 30% <0.001 Hospital mortality 32% 38% patients with Positive Blood Cultures Fungal infections OR 2.8 OR 1.7 HCA infection OR 1.6 * * * * * * * * * * * * Inadequate antibiotics OR 1.4 * Granja, Plos One 2013, 8: e53885 Gonçalves-Pereira, Clin Microbiol Infection, 2013, 19: 242 *p<0.05

14 Seasonal distribution of infections Spring Summer Fall Winter Respiratory Neurologic Urologic Intra-Abdominal Skin and soft tissues Ginecologic-obstetric Endovascular Other 0 Other Urological Skin Bacteremia Abdominal Pneumonia

15 Seasonal distribution of infections Other Urological Skin Bacteremia Abdominal Pneumonia Pneumonia 31.6% 37.8% Abdominal 41.5% 37.1% Death Survivors Spring Summer Fall Winter Spring Summer Fall Winter

16 CRP ratio Process of Care Early appropriate antibiotic therapy Mortality and Time of Antibiotic Therapy (<3h/ 3h) N <3h 3h OR 95% CI P Total % 32.6% Documented Infection % 37.9% Septic Shock % 45.4% Antibiotic adequacy 81.6% 1,2 1,1 1 0,9 0,8 0,7 0,6 0, Day Gonçalves-Pereira, ATS 2011 P B104 <3h 3-12h >12h

17 Process of Care Early appropriate antibiotic therapy 90% 80% 70% 60% 50% 40% 30% 20% 10% Time until antibiotic therapy 2.30h 0% Community Health Care Hospital <3h >3h 75% Appropriate Inappropriate 40% 20% 20,1% 19,8% 50% 25% 26,7% 50% 0% Mortality 0% ICU Mortality OR 2.75 ( )

18 Admission delay Process of Care 3±6 days The mortality rate was similar in patients with CAI admitted directly to the ICU or first to the ward (35.9% vs. 35.1%, p=0.78) 2±2 days The mortality rate was similar in those admitted directly to the ICU or first to the ward (32% vs. 29%) An increase in CV failure was noted, from 8.6% at D0 to 51% at admission to the ICU Povoa, Crit Care Med, 2009, 37: 410

19 Process of Care Microbiology Only 48.3% documented infections (50.9% of hospital-acquired infections) Blood cultures were collected in 48% of CAI patients Collection was associated with a decrease in mortality OR 0.57 ( ) Cardoso, Crit Care, 2010, 14: R83 Post ICU Mortality 11.4% (infected) vs. 11.4% (non infected) 14.2% (infected) vs. 9.6% (non infected), p<0.001

20 Process of Care ICU acquired infection In the overall population an ICU acquired infection was associated with an increase in mortality OR 1.55 ( ) In the infected population a new ICU acquired infection increased mortality OR 2.16 ( ) Gonçalves-Pereira, Clin Microbiol Infection, 2013, 19: 242

21 Conclusions Population characteristics were similar in (2005) and (2010) studies Infected patients are roughly 40% of all ICU admissions and 50% presented in septic shock Health care associated infections are frequent and commonly present resistant microrganisms Changes in the process of care may help to improve the outcome of the infected population

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